Comparison of intraoperative neural monitoring between endoscopic transoral and bilateral axillo-breast approach thyroidectomy.

BACKGROUND: The use of intraoperative neuromonitoring (IONM) during endoscopic thyroidectomy has not been fully explored, with limited studies focusing solely on the recurrent laryngeal nerve (RLN) and neglecting the external branch of the superior laryngeal nerve (EBSLN). This study aimed to compare the effectiveness of IONM in two endoscopic thyroidectomy techniques, namely the transoral and bilateral axillo-breast approach (BABA). METHODS: We retrospectively reviewed patients who underwent endoscopic thyroidectomy with IONM and compared the outcomes between those who underwent different surgical techniques (transoral or BABA). We recorded the detection method and identification rate of the EBSLN and RLN, along with the amplitude and latency of the evoked potential. RESULTS: We monitored 98 nerves at risk (NAR) from 74 patients (60 and 38 in the transoral and BABA groups, respectively). Almost all EBSLNs were identified using electromyography (EMG) signals and/or cricothyroid muscle twitches, except for one patient in the transoral group who developed EBSLN palsy. Patients in the transoral group were more likely to have the sternothyroid muscle divided (75.0% vs. 15.8%, p < 0.001) and had a lower rate of visual recognition of the EBSLN fibers (10.0% vs. 31.6%, p = 0.007) than did those in the BABA group. All RLNs were identified in both groups; however, patients in the BABA group had a relatively higher rate of post-dissection amplitude reduction > 50% (15.8% vs. 5.0%, p = 0.072), and one patient had transient RLN palsy. CONCLUSIONS: Both the EBSLN and RLN could be adequately identified and monitored during endoscopic transoral and BABA thyroidectomies using IONM.

Neck Reoperation for Recurrent or Persistent Renal Hyperparathyroidism.

BACKGROUND: Patients with renal hyperparathyroidism undergoing parathyroidectomy may experience relapse. Reoperation for persistent or recurrent disease, particularly in the neck region, is challenging and has a high complication rate because of difficult exploration. We aimed to evaluate the effectiveness of neck reoperation in renal hyperparathyroidism. METHODS: Patients with recurrent or persistent renal hyperparathyroidism who underwent neck reoperation between January 2015 and August 2022 were investigated, focusing on operative findings, perioperative biochemical changes, and significance of intraoperative parathyroid hormone (PTH) measurements. RESULTS: During reoperation, 35 parathyroid glands were identified and removed from the 26 enrolled patients, with one, two, and three glands retrieved from 19 (73.2%), five (19.2%), and two (7.6%) patients, respectively. Most removed glands (68.6%) were located in the lower neck, followed by the mediastinum, carotid sheath, and upper neck. Successful resection, defined as a postoperative PTH level of <300 pg/mL, was achieved in 21 patients (80.8%). The remaining four (15.4%) and one (3.9%) patients were classified as having persistent and recurrent disease, respectively. The extent of PTH reduction was correlated with specimen weight, specimen volume, and preoperative alkaline phosphatase (ALP) level. The mean intraoperative PTH ratio (10 min after excision/pre-excision) was 0.23, and all patients with persistent or recurrent disease had a PTH ratio >0.3. Severe hypocalcemia (<7.5 mg/dL) occurred in 19 (73.0%) patients after reoperation. CONCLUSIONS: Neck reoperation is an effective therapeutic option in patients with recurrent or persistent renal hyperparathyroidism. A decrease in PTH level by >70% during reoperation (PTH ratio <0.3) predicts successful resection.

Multimodal Assessments of Altered Sensation after Transoral Endoscopic Thyroidectomy.

BACKGROUND: Transoral endoscopic thyroidectomy, a novel technique, uses oral vestibule as the entry point and leaves no scar on the body surface. However, because the incisions are close to the mental nerve, nerve damage and the associated sensory impairment are concerning. Herein, we evaluated sensory alteration after transoral endoscopic thyroidectomy and determined factors associated with the prolonged sensory alteration. METHODS: Patients who underwent transoral endoscopic thyroidectomy were enrolled. Sensation over the lower lip, chin, and neck was evaluated before and after the surgery. A self-assessment questionnaire, Semmes-Weinstein monofilament test, and two-point discrimination test were used to subjectively and objectively evaluate sensory changes. RESULTS: Fifty-one patients were enrolled; most of them reported altered sensation, with chin (72.5%) being the most common site, followed by lower lip (52.9%), upper neck (33.3%), and lower neck (5.9%) on postoperative day 2. The sensory disturbance resolved within 3 months. Factors associated with prolonged sensory alteration are male sex and old age. Fourteen patients (27.5%) experienced mild drooling from the mouth, which was usually self-limiting in 1 month. Sensory impairments in light touch pressure threshold and two-point discrimination were significant in the chin and neck on postoperative day 2 and at 1 week. The ability to discern two-point was also compromised in the lower lip on postoperative day 2. All these significant changes normalized to preoperative baseline at 1 month. CONCLUSIONS: There was an altered sensation after transoral endoscopic thyroidectomy with the most common and disturbed in the chin. Sensory impairment was usually transient and recovered in 3 months.

Multidimensional Analyses of the Learning Curve of Endoscopic Thyroidectomy.

BACKGROUND: Endoscopic thyroidectomy has comparable surgical outcomes and superior cosmetic satisfaction to open thyroidectomy. However, steep learning curve is a concern. This study evaluated the learning curve of endoscopic thyroidectomy using various parameters and statistical methods. METHODS: A total of 90 consecutive patients who underwent endoscopic thyroidectomy using bilateral axillo-breast approach (BABA) between March 2016 and April 2020 were enrolled. Operative time, postoperative drainage amount, and blood loss were assessed by cumulative sum (CUSUM) analysis and moving average to evaluate the learning curve. RESULTS: Using the CUSUM analysis, the peak point of both operative time and drainage amount occurred at the 30th case. No clear single peak was identified in the CUSUM plot for blood loss. The moving average also showed significant reduction in operative time and drainage amount after, approximately, the first 30 cases. The blood loss decreased after the 25th case. We therefore divided the patients into 2 phases: phase 1 (1-30 cases) and phase 2 (31-90 cases). The operative time, drainage amount, and blood loss decreased significantly in the phase 2 compared with phase 1. Lower pain score in first postoperative day and shorter hospital stay were also observed in the phase 2. Although the reduction in transient hypoparathyroidism did not reach statistical significance, no permanent hypoparathyroidism was noted in the phase 2. CONCLUSIONS: The learning curve for endoscopic thyroidectomy is approximately 30 cases. Aside from the operative time, drainage amount may also serve as a surrogate for the learning curve evaluation.

Outcome Comparison between Endoscopic Transoral and Bilateral Axillo-Breast Approach Thyroidectomy Performed by a Single Surgeon.

BACKGROUND: The transoral approach and the bilateral axillo-breast approach (BABA) are remote access approaches for endoscopic thyroidectomy. Both follow a symmetric design and use CO2 insufflation to maintain the working space. The outcome differences between the techniques are rarely compared in the literature. METHODS: All patients who underwent endoscopic transoral (n = 72) and BABA (n = 63) thyroidectomy between October 2018 and August 2020 by a single surgeon were retrospectively reviewed. The following peri-operative data were collected and compared: operative time, blood loss, postoperative drainage amount, hospital stay, pain score, number of retrieved lymph nodes, and complications. RESULTS: Patients in the transoral group were younger (44.7 vs. 49.3 years, p = 0.022) and had smaller tumors (2.4 vs. 2.8 cm, p = 0.020) than those in the BABA group. The operative times were significantly longer in the transoral group than in the BABA group (lobectomy, 194.1 vs. 177.0 min, p = 0.026; total thyroidectomy, 246.0 vs. 214.3 min, p = 0.042). Nevertheless, the time difference became insignificant after completing the initial 20 cases of transoral thyroidectomy. The drainage fluid collected after the surgery was serosanguinous, and a lower drainage volume was observed in the transoral group than that in the BABA group (64.9 vs. 78.5 ml, p = 0.017). However, there was no significant difference regarding the blood loss, hospital stay, postoperative pain score, and lymph nodes retrieved. The rate of postoperative complications, such as hypoparathyroidism and vocal cord palsy was comparable between the two groups. CONCLUSIONS: Transoral approach and BABA are comparable with regard to surgical outcomes. Selected patients may choose either technique based on their preferences.

Vocal cord granuloma after transoral thyroidectomy using oral endotracheal intubation: two case reports.

BACKGROUND: Transoral thyroidectomy can be performed using nasal or oral intubation. Recently, we encountered two cases of vocal cord granuloma that were suspected to result from intraoperative compression by the oral endotracheal tube. CASES PRESENTATION: Two women underwent transoral endoscopic thyroidectomy with oral endotracheal tubes fixed at the mouth angle. Their initial postoperative recovery was uneventful, but they developed hoarseness 2 months after the surgery. Subsequent strobolaryngoscopy revealed vocal cord granulomas at the side of contact of the endotracheal tube. One patient received medication and voice therapy, and her granuloma shrank significantly one month later. The other patient underwent granuloma resection. Thereafter, the symptoms improved in both the patients. CONCLUSIONS: Oral intubation with tube placement at the mouth angle might result in the formation of vocal cord granulomas. Therefore, we suggest positioning the tube at the midline to avoid excessive irritation on one side of the vocal cord.

Correlation of 18F-FDG uptake and thyroid cancer stem cells.

BACKGROUND: 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography (18F-FDG PET) has the potential to detect various types of cancers, including thyroid cancer (TC), at a potentially curable stage. Increased uptake of 18F-FDG was observed in anaplastic and poorly differentiated thyroid cancer cells, and PET-positive tumors are more likely to be resistant to 131I treatment. As cancer stem cells (CSCs) possess a dedifferentiated phenotype and are resistant to many anticancer therapies, we hypothesized that the expression of CSC-related markers is correlated with the ability of tumor cells in TC to uptake FDG. METHODS: The present study cohort included 12 patients with TC, who underwent 18F-FDG PET/CT imaging before surgery. Quantitative polymerase chain reaction (QPCR) and immunohistochemical (IHC) staining were performed to analyze the expression patterns of gene markers related to embryonic stem (ES) cells and CSCs in TC. RESULTS: The mRNA expression levels of CSC- (CD133 and CD44) and ES-related genes (Oct4 and Nanog) were higher in TC tissue than in normal thyroid tissue, whereas the mRNA expression levels of thyroid-specific genes (Tg, TSHR, and TTF1) were higher in normal thyroid tissue than in TC tissue. There was a positive and statistically significant correlation between FDG uptake (SUVmax) of tumor and relative mRNA levels of CD133, CD44, Oct4, and Nanog. The IHC results demonstrated that CD133 and Nanog were expressed in TC tissue but not in normal thyroid tissue, however, CD44 expression was observed in both TC and normal thyroid tissue. Comparisons of the clinicopathological parameters between TC tissues with low and high SUVmax demonstrated significant differences in protein level of CD133 but not in that of Nanog. CONCLUSIONS: The pre-therapeutic tumor SUVmax obtained from 18F-FDG PET/CT may be a potential predictor for evaluating the proportion of CSC population in individual patients with TC.

Foley Balloon Facilitates Creation of Working Space in Transoral Thyroidectomy.

BACKGROUND: Transoral thyroidectomy via the vestibular approach retains no scars in the body surface and is a good option for patients indicated for thyroidectomy but with cosmetic concerns. However, the working space of this procedure is relatively small and is also difficult to create compared with that of other remote-access thyroidectomy procedures. METHODS: In this study, we first created a tract from the chin to the sternal notch, after which a Foley catheter with stylet was inserted through the middle oral incision. Sequential balloon insufflations were performed to dilate the entire subplatysmal tunnel. RESULTS: After Foley catheter dilatation, the subplatysmal space was larger, and subsequent trocar insertion became much easier. With the help of a balloon compressing the surrounding tissue, hemostasis was secured and a clearer tissue plane could be identified for subsequent sharp dissection. CONCLUSIONS: Foley balloon dilatation is a simple, effective, and low-cost technique that overcomes the difficulty in creation of working space during the initial stage and can be applied to all transoral thyroidectomy procedures.

Analysis of gallstone disease after gastric cancer surgery.

BACKGROUND: The incidence rate of newly developed gallstone disease after gastrectomy for gastric cancer is thought to be higher than that in the general population. However, the presentation and management of these gallstones remain under debate, and the role of prophylactic cholecystectomy remains questionable. METHODS: Data on adult patients who were diagnosed with gastric cancer and received gastrectomy between 2000 and 2011 were extracted from the Taiwan National Health Insurance Research Database. A patient was excluded if he or she had gallstone disease or received cholecystectomy before the index date. The incidence of newly developed gallstone disease and its subsequent management were recorded. Data were analyzed to evaluate the factors associated with gallstone development and treatment options. RESULTS: A total of 17,325 gastric cancer patients who underwent gastrectomy were eligible for analysis. During the follow-up period (mean 4.1 years; median, 2.9 years), 1280 (7.4%) patients developed gallstone disease and 560 (3.2%) patients subsequently underwent cholecystectomy. The in-hospital mortality for cholecystectomy was 1.8% (10/560). Development of gallstone disease was associated with older age, total gastrectomy, duodenal exclusion, diabetes, cirrhosis, and more comorbidities. Factors associated with the use of cholecystectomy to treat gallstone disease included younger age, fewer comorbidities, medical center admission, and presentation as cholecystitis. CONCLUSIONS: Although few patients required further gallbladder removal after gastrectomy for gastric malignancy, the increased mortality rate for subsequent cholecystectomy was worth noting. The decision to undergo prophylactic cholecystectomy might be individualized based upon patient characteristics and the surgeon's discretion.

Recurrence after skin-sparing mastectomy and immediate transverse rectus abdominis musculocutaneous flap reconstruction for invasive breast cancer.

BACKGROUND: The aim of this study was to evaluate the recurrence pattern after skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) using transverse rectus abdominis musculocutaneous (TRAM) flap in patients with invasive breast cancer. METHODS: From 1995 to 2010, patients with invasive breast cancer who underwent SSM followed by IBR using TRAM flap were retrospectively reviewed. The pattern of the first recurrence event was recorded. RESULTS: We identified 249 consecutive patients with invasive breast cancer, two-thirds of whom (67.1%) were diagnosed with stage II or stage III disease. During a median follow-up period of 53 months, three (1.2%) local, 13 (5.2%) regional, 34 (13.7%) distant, and five (2.0%) concurrent locoregional and distant recurrences were observed. The median time to recurrences was 26 months (range, 2 to 70 months) for all recurrences, 23 months (range, 2 to 64 months) for locoregional recurrences, and 26 months (range, 8 to 70 months) for distant recurrences. All local recurrent lesions were detectable by careful physical examination, and detection of local recurrence suggested the presence of distant metastasis (60.0%). In contrast to distant metastasis, the risk of locoregional recurrence did not increase significantly with an increase in disease stage. The 5-year overall, locoregional relapse-free, and distant relapse-free survival rates were 89.7%, 90.8%, and 81.6%, respectively. CONCLUSIONS: SSM followed by immediate reconstruction using TRAM flap is an oncologically safe procedure even in patients with advanced-stage disease. Detection of local recurrence is crucial and can be aided by a thorough physical examination.

Balloon-occluded retrograde transvenous obliteration for intractable gastric variceal bleeding.

Balloon-occluded retrograde transvenous obliteration (BRTO) is an interventional radiologic technique that obliterates gastric varices (GV) from draining veins under balloon occlusion. A 54-year-old man presented with Stage IV hepatocellular carcinoma and tumor thrombi in main portal vein. Intractable GV bleeding had no response to repeated endoscopic sclerotherapy and pharmacotherapy well. Additionally, his medical condition could not allow transjugular intrahepatic portosystemic shunt or surgical portal decompression. Due to spontaneous gastrorenal shunt proved with abdominal computed tomography, we conducted BRTO to prevent further bleeding. The immediate postprocedural venogram showed total occlusion of the gastrorenal shunt and no visualization of the GV. Follow-up endoscopy was performed at 1 month, 2 months, and 4 months after BRTO. It revealed shrinkage of gastric varices and no worsening of esophageal varices after 4 months of BRTO. The patient was free from repeated GV bleeding for 4 months. Our experience proved BRTO could be the other effective treatment for intractable GV bleeding.

Pre-incisional, trans-isthmic injection of indocyanine green for lymph node mapping during the transoral endoscopic thyroidectomy vestibular approach.

Indocyanine green (ICG) is a useful tracer for lymph node mapping and retrieval. However, during endoscopic surgery, it is challenging to administer ICG into the thyroid without spillage. We developed a simple technique of delivering ICG, thereby preventing leakage. Patients who underwent the transoral endoscopic thyroidectomy were retrospectively reviewed. In 20 patients, who constituted the ICG group, 0.1 mL ICG was injected into the peri-tumoral space under ultrasound guidance, soon after the patients received general anesthesia. Patients with papillary thyroid carcinoma who did not receive the ICG injection comprised the control group (n = 43). The location, size, and number of harvested lymph nodes were recorded in conjunction with parathyroid-related parameters. No ICG spillage occurred in the ICG group, and 76 ICG-stained lymph nodes were detected in the pretracheal (57.9%), paratracheal (25.0%), and prelaryngeal regions (17.1%). The ICG group demonstrated a significantly higher number of total (5.3 vs 2.1) and metastatic (1.5 vs 0.6) lymph nodes, a larger metastatic deposit in the positive node (3.5 mm vs 1.6 mm), and a higher rate of pathologically node-positive disease (70.0% vs 27.9%) than did the control group. The postoperative calcium level (7.8 mg/dL vs 7.2 mg/dL) was also higher in the ICG group. Pre-incisional, trans-isthmic injection of ICG under ultrasound guidance is a simple technique to prevent the leakage of ICG. Under fluorescence imaging, an adequate number of lymph nodes can be harvested for examination, which may assist in intraoperative decision-making.

How Soda Ingestion Facilitates the Distinction between a Killian-Jamieson Diverticulum and a Malignant Thyroid Nodule.

A 66-year-old woman presented with an incidental left thyroid nodule during a health examination. She had no voice change, shortness of breath, cough, or dysphagia. Repeated sonography showed a dynamic change of the lesion, which was more evident following soda consumption. A subsequent esophagography confirmed the diagnosis of a Killian-Jamieson diverticulum. This rare left-sided pharyngoesophageal diverticulum is often asymptomatic. On a sonography, air bubbles in the esophageal lumen can cause a ring-down artifact that mimics microcalcifications, which are characteristic of thyroid malignancy, and misdiagnosis may lead to unnecessary interventions, including fine-needle aspiration or thyroidectomy. A dynamic ultrasound, specifically done during soda consumption, offered a simple diagnostic distinction. No surgical intervention was pursued; the patient was monitored in the clinic.

Laparoscopic versus open subtotal gastrectomy for locally advanced gastric cancer: A retrospective analysis from a single institution.

BACKGROUND: /Objective: Laparoscopic distal gastrectomy for early gastric cancer is described as a treatment option in general practice. However, the oncological efficacy and technical safety of laparoscopic gastrectomy with D2 lymphadenectomy in locally advanced gastric cancer are controversial, and clinical trials are ongoing. This study aimed to evaluate the short-term and surgical outcomes between laparoscopic and open gastrectomy procedures in locally advanced gastric cancer. METHODS: We retrospectively analyzed data from 134 patients who underwent subtotal D2 gastrectomy for locally advanced gastric cancer in our hospital between January 2011 and December 2018. Clinicopathological characteristics, surgical outcome, postoperative recovery, disease-free survival, and overall survival were compared between those who underwent laparoscopic and open gastrectomies. RESULTS: Baseline characteristics were similar between patients who underwent open and laparoscopic surgeries. Less surgical time (250.8 vs. 347.6 min in laparoscopic vs. open surgery, respectively; P < 0.05) and lower blood loss (83.7 vs. 333 mL in laparoscopic vs. open surgery, respectively; P < 0.05) were noted in patients who underwent laparoscopic surgery than in those who underwent open gastrectomy. The time of starting oral intake was earlier and the length of postoperative hospital stay was shorter in the laparoscopic group than in the open group. Surgical morbidity and mortality rates, as well as disease-free survival and overall survival rates, did not differ between the two groups. CONCLUSION: Laparoscopic gastrectomy is feasible and safe for locally advanced gastric cancer. Based on the perioperative results and short-term outcomes, laparoscopic gastrectomy is non-inferior to open gastrectomy.

Cannula Fracture during Transoral Endoscopic Thyroidectomy Vestibular Approach: Causes and Prevention.

In the transoral endoscopic thyroidectomy vestibular approach (TOETVA), three oral vestibular incisions are used to access the thyroid. This approach leaves no scar on the body surface; however, unexpected complications may occur. Three patients (two women, one man) underwent TOETVA using the standard three-port technique. Broken cannulas of the 12 mm central port were noted in all cases. All cannulas broke on the ventral side of the distal shaft. The fracture lines were 3-4 cm in length, with some fragments scattered throughout the operative field and oral cavity. The fractures were caused by compression against the mandible while tilting the cannula during surgical manipulation. Male sex, short stature, and protruding chin may be risk factors for cannula fracture in TOETVA. Measures should be taken to prevent this complication, particularly in high-risk patients.

Working Space Creation in Transoral Thyroidectomy: Pearls and Pitfalls.

Transoral thyroidectomy is a novel technique that uses three small incisions hidden in the oral vestibule to remove the thyroid gland. It provides excellent cosmetic results and outcomes comparable to the open approach. One of the main obstacles for this technique is the creation of a working space from the lip and chin to the neck. The anatomy of the perioral region and the top-down surgical view are both unfamiliar to general surgeons. As a result, inadequate manipulation might easily occur and would lead to several unconventional complications, such as mental nerve injury, carbon dioxide embolism, and skin perforation, which are rarely observed in open surgery. Herein, we summarize the basic concepts, techniques, and rationales behind working space creation in transoral thyroidectomy to assist surgeons in obtaining an adequate surgical field while eliminating preventable complications.

Indocyanine Green Angiography for Parathyroid Gland Evaluation during Transoral Endoscopic Thyroidectomy.

Indocyanine green (ICG) angiography, a real-time intraoperative imaging technique, is associated with better parathyroid identification and functional evaluation during open thyroidectomy. However, the benefits of ICG fluorescence imaging application in transoral endoscopic thyroidectomy are not well-documented. Consecutive patients who underwent transoral endoscopic thyroidectomy were retrospectively reviewed. Parathyroid glands were assessed with visual inspection followed by ICG angiography. The fluorescence intensity of all parathyroid glands was recorded. In total, 158 parathyroid glands from 60 patients (41 underwent lobectomy and 19 underwent total thyroidectomy) were eligible for evaluation. A total of 135 parathyroid glands (85.4%) were identified, including nine glands (5.7%) that were solely localized because of ICG angiography. Incidental parathyroidectomy occurred in 12 patients with predominant inferior gland (83.3%) and associated with central neck dissection (66.7%). Among patients receiving total thyroidectomy, patients who retained at least one well-perfused parathyroid gland had higher parathyroid hormone (PTH) level and were less likely to develop hypoparathyroidism on postoperative day one than those without any well-perfused ICG-enhanced parathyroid gland (p = 0.038). In addition, the duration of calcium supplementation to maintain normocalcemia was also shorter. ICG angiography is a feasible adjunct procedure for parathyroid identification and postoperative functional prediction in transoral endoscopic thyroidectomy.